S 0248 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.E.EM RICAL P fT No
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECIIANICAL v 0248
H
BUILDING PROJECT IDENTIFICATION
BUILDING ADURMS: SANITARY NO, APl'I.ICAI'IIOO/NN SUBMITTAL DATE
0-7 7'�C;7— Fs000r
T. !/ 1
OWNER'S NA G:� PHONE: CONTRACTORS NAME: - NO:
NIC CONTROL#
�ARCIIRECT/ENGIMJiR: LIC NO: ADDRESS: �xst �s�j� � ElCkx RL-Wk-
CONTACT PHONE;: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) 1 Ii ELECT PLUMB MECII
LICENSED CONTRACTOR'S DPAhARAnON QTY ELECTRIC PERMIT FEE
ilnmt tlw 1 am liceiased under pmvisioiu N CTvPtec 9(commene" JOB DESCRIPTION
ZOMIIof Diviskw)MIM 9usitsu vM Wnnl�ca�itms Ga�Nc�.-a/nd myll¢nsei.r PERMIT ISSUANCE RESIDENTIA_ c0 e,, 1 ❑SUDWI. ❑IOTCHENREMODEL
F<FUVAl'PLIANCRS-RI5101iNTIAL ❑AUDITION ❑PLUMBING RE-PIPE
N<e..Zal Cu DED. C ❑MULTLUNIT ❑SIRUCTURAI,
ARCHfitiCTS DECLARATION
z0 Z l utukrwmnl.,,I...
Hull hcuW upaMc made 10\NEIS MODIFICATION
�+ UPTO200AMPS
OZ-0 - []INTERIOR ❑CHIMNEYREOIR
FLICuI Licenxd Podewsiurul 201-1000AMPS IMPROVEMENT 0SWIA1A11NG P(%ILS
So,,^{� OWNER BUILDER DECLARATION OVER I(gg1AMPS ❑BATH RFMODFJAtFPAIR ❑DEMOI,TION
W C Q 1 hereby ufGnn Im hm I ueIemfl from the 00.0."Liana lawlards,
mo
i U following mason.(Strasto 111 Busima;and Pmfessiade:a CoAny city or CT
ream, SIGNS ELERICAL
F' ❑OTHER
If W F which requires a permit m lar"aact utter,impnivc,ikninl.......mpn
mr- I -_ urse
prim to its iwsuarwe,alto requites do applicant fa such pmnui to file nopoid wcttlem SPECIALCIRCUITAIP.
then he is Bawd Ft n rm la the ynwicionr of the Can,.,o r'I License law(Claimer 9
QO2 ("Oran ing with Saheb MXB ofDT,Lean J of that Buairceaatd Pmfcasions CnJe)or TIJHP.METER OR POLII INST. COMMERCIAL'
a
her he is e,o thertftan arid the hosts f r the allegW c,oar inn.Any violathm of ❑NEW BLDG/ADDI'I'ION ❑DEMOLITION
Section 10313 by any applicant fora Permit subjects the epplic-auu to a evil Penalty of POWER DEVICES ❑TENAT ❑FOOD SERVICE
y, iw a#Xe Nan five hundred to($5013) IMPROVEMENT
O ❑I.uowtcr of the ptsgscnY ar mY eieiployees with wa%ecudieir role eampettsvion, SWIMMING P(K)L ELECTRIC
pp(�iiGG''. will mnlr wrrk.Intl are umclum is not in¢tdW m oRetM fm sale(SeeAna,Bmimv [I OTHER
LL13 and Profeuirms Cade: He Coarm or'r License law Jaw not apply mOUTLETSan owner Of -SW ITCHES-ETI
FIXTURES
A. popvty who Imi1Ja or imptavo Ecreao,and wloo docs such work hmself or thmagh NEW HISIUIlT'rlAl.E.ECIR SQ 1�'.
his Own employees,Moiled that such iniProm
vemnts vR not intended!or offered hr
sile.If,Mmn.thc building a mrnt soproseis.sold win.me year MrnmPletiun,the SQ,FT FLOOR AS SISQ.FI'.
a,vocoh older will have IM harden of proving ran he did nm build in improve lir Par
pae of sok.).
Ej 1,ux of the PnTcny,a aclueisel,""loading with IiccmnrA cnnwclmfi ITOTAL
emvrvctthe project(Sec.1011.Ban.aM Pmfwions Cade:)The Com aclaw"U-
nsclawarandlepplyt0onawncrnfProPrnywhobuildnaimlrnses 1lCrwm.vel QTY, PLUMBING PERMIT PEE
ewh,cau 'fasuch faojerbwiN vemtnctoetsl imemed funavntmUse ContmetNa
Linen¢Low. 14ERM11'ISSUANCE
CD L vin csempt anter Sec. .R&I'C for do,twnn
AI.TER-DRAIN&VEST-WATER IFA) VALUATON
Owrcr Dene
WORKERS COMPENSATION DECLARATION BACK V1AW PROTECT.DEVICE
I hereby.toren Malar penally of Perjury one or the follassing Jcclurminnv:
Ihave sold will ttminlain•CmJ roof C.nsenno mlf-insure fa WmkrlaCmmpem DRAINS-FLOOR.ROOF,AFEA.COND. '1'YEi CONSTRULTON
xmitm,us pmviMtl f r hY Sctiim MID M the is Citic,Lr Etc pcnanionae of IhC STORII?
wxt far which Nis pvntit is iswsed. FIXTURES-PER TRAP -
❑ I leve abu will im inloin Witter's Con,cm alien Insurance,no,motored by Se tial
3100of the Lahr Code.fm theperfmt ad do wank fa which this Pemut IT iroad GAS-1:1.SYSTLN-I INC d OUf.E OCC AI'N
My Worker',Con,ri,iion Inwmrxe cmnur and Pelt,,mumlberum:
Cartier: Policy No: GAS-la.SYSTEM-0V ER 1(G)
CERTIFICATE.OF EREAIPIDON FROM WORKERS C I I UC UUf cIINU
COMPENSATION INSURANCE GREASMNDUSTRL WASTE,INTERC TTUR BUILDING DIVISION
(Thisreclierneed nal ActimPltad ifibepasnil sfernnehintooddtdlars($100) GREASE'FRAI'
a lu..l PIANCHF,CK FEB
Icrnifythal inllepeK xeafthe we LrwM1icnthisPcmmilisiw d.lshall Sl:WEH-SANITARY-S'IURMEA.2NIPP
not en, tayen iany nbu n hjeclln the Woders'Co.,.-- EN RGY FEE
o z w inn law fCilif Dat WATER HEATTIR WNIiNDE1.I:CTR GRADING FEE
ZO Applicant
NODCf:T(1 I.ICAI t making thio Cmifimte of Gemryion,yw rtoold WATER SYSTEAI000HATING
a ? beconm w 'set to IM1e W a C npcnwlinn pnrvisinm o(the WMr Cale,You roostS(lI1S INA
W foMwi mplY wiN auc si«nmthis Mrmit shallhdecncd maMi WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENDAL PLMB. SQ.FT PAID
Z)z Doc Rarip N
U O 1 to affirm near Nem is a construction lending agency fa the pa fantance al -
IL � the work for which Nis pcmtit u owned(Sec.:RN7.Civ.C.) TGTAI,:
I'Mcrs Name
V L.eNcr's Addrtu TOTAL:
BJ
1 cmify NY 1 have vJ Nia aPPlicelion and sem tit the aMive inrmmuian is BUILDING
Ton cxm't l agtec m canPly wiN ell city aid crvnry aNnaires and slam law.mlating e. QTY. MECHANICAL PERMIT FEE
V Z building comaaction,anal henoaudonne mPres<nmlives Of Nis city io enter upon the SEISMIC FEE
'--� ahuve mentilmM pmpcny In....pe Iron purpn PERMIT ISSUANCE
sas<,iidemtufy etd keep leu the City of Culsrtim it'into ELECTRIC IEE
i cs.j Wgnnm� rtrarWT aw'1 ay' anywaor
y ecr:mc ageing said City ALTER OR ADD TO MECII.
iocaaeANTU DE gnf this PLUMBING ETF.
APPLICANT UNDER5 ANUS AND 1 L , MPLY WITII ALL NON-POINT AIR HANDLING UNITGD 1".(MCFM)
SOURCE RF.GUfATIO MECHANICAL
AIR HANDLING UNIT(OVER 10,010 CFM) CONSTRUCTION TAX
(dc�o
mofApplicvnVCa D c P HAUSTHOOD(WIDUCE HOUSINGMI'FIGAPIONFEE
HA' )US M1 TER
DISCLOSURE
Wll the vpPli i futumbuldi g occupant slam mhaNlc haemikxir mammal HEATING UNIT(TO 14),(w BTU)
by the C no Marcid I ..Je.Clarter 9.12,ad te HeaLN and Safety
miun 8332 a) IIFATING UNIT(OVER I(p.fMkT RTU)
�Yo i VE"LATION FAN(SINGLE RESIDE PAID
which
Will the ugilrunt a forum buiding occupant use equil'nlan or do which HecciPi X
emit beaMws air comaridtianm as defircal M line Bay Ama Air Quality Marugement ROILER-COMP OHP OR 1(1(1.000 BTU)
Dlnncl^ T 'A I;
Yo - BOLER-COMP(OVFA IW."BTU) _
�\ AIR CONGO'IONER
I have emdlm neaudou. '�iegtiircrtrnt: )Cbepur 6.95 of the Caf� ISSUANCE DATE
Hxnia Health&S,t ly r 2595, III a .1 unlmhr al Nal if the NI?w REi1DPNf1A1.MACH, SQ,FI'. 4
building ntly bave lit ism .il+itry to iwufy the ueopmx l
arsH whim must co o' enfaC ifealenf Oc.'ncy.
/ `
C uuthrto agora Dem TOTAL ISSUE.,BY: OI
OFFICE
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